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EDUCATIONAL WORKSHOPS 2009. CASE PRESENTATION ONE. ‘B’ is for ‘Bone’ A case of Clupea harengus var rubrum Author: Peter Cowling, North Lincolnshire & Goole Hospitals. - PowerPoint PPT Presentation
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EDUCATIONAL WORKSHOPS 2009
CASE PRESENTATION ONECASE PRESENTATION ONE
‘B’ is for ‘Bone’A case of Clupea harengus var rubrum
Author: Peter Cowling, North Lincolnshire & Goole Hospitals
Sponsored through an unrestricted educational grant from Novartis Pharmaceutical Ltd to help support the
cost of developing and hosting this educational workshop series
Presentation62 yr old femaleEmergency admission: Fever 38-39o
Rigors Vomiting Sudden onset
Author: Peter Cowling, North Lincolnshire & Goole Hospitals
Past Medical History1989 -Type 2 DM 2000 – Insulin dependent. HbA1C 14.5PVDPNCharcot’s3x4cm ulcer on sole L footRetinopathy
Author: Peter Cowling, North Lincolnshire & Goole Hospitals
Past Medical History2006 - Sigmoidectomy for diverticular diseaseAnaemia 2o vaginal polypsBronchiectasisHypertensionJun-Aug 2007 - Staph aureus paronychia
Author: Peter Cowling, North Lincolnshire & Goole Hospitals
ExaminationOverweight. BMI = 38Flushed, sweaty. Temp 37.8o
HR 110 bpm I + II + ASMBP 120/60Chest clearAbdo NADDiabetic feet as above
Author: Peter Cowling, North Lincolnshire & Goole Hospitals
InvestigationsHb 9.5WCC 12.0CRP 256MSU - +ve dipstix, micro haematuria, pyuria + coliformUlcer swab – mixed enteric flora swab in OPD 2/52 previously enteric flora + Staph aureusBlood cultures
Author: Peter Cowling, North Lincolnshire & Goole Hospitals
Treatment Day 1Trimethoprim for presumed UTI. Coliform sens to co-
amox, trim, nitro. Resistant to amox. Trim continued after urine C&S result
Author: Peter Cowling, North Lincolnshire & Goole Hospitals
Day 2Blood culture positive for GPC ?strepAmoxicillin added to trimethoprimNo specific treatment for ulcer
Author: Peter Cowling, North Lincolnshire & Goole Hospitals
Day 3Blood culture – Group B strepSens pen, clari, clinda, synergistic genta, resistant to tetraAmoxicillin & trimethoprim continuedMicrobiologist advised investigations to exclude IE.
Noted past GBS in abdo wound.TTE & TOE mild thickening of leaflets MV & TV.
Otherwise normal. No vegetations
Author: Peter Cowling, North Lincolnshire & Goole Hospitals
Day 7Well, apyrexial, WCC 10.4, CRP 532 sets blood cultures negativeDecision to stop antibiotics at 1/52Discharged home
Author: Peter Cowling, North Lincolnshire & Goole Hospitals
1 week laterEmergency admissionUnwell, rigors, vomiting for 3/7. 1x diarrhoeaFrequency + ‘smelly urine’GP gave ciprofloxacin following +ve dipstix previous day
Author: Peter Cowling, North Lincolnshire & Goole Hospitals
ExaminationAlert, orientated, sweatyT= 37.7o
HR 110, I + II + ?ASMBP 125/90Chest + abdo clearOsplinters / Janeway / Osler’s
Author: Peter Cowling, North Lincolnshire & Goole Hospitals
InvestigationsHb 8.7WCC 13.0CRP 410+ve dipstix
Author: Peter Cowling, North Lincolnshire & Goole Hospitals
Day 1Called MicrobiologistAdvised IV co-amoxiclavFurther blood cultures and further advice if not settling2 sets blood cultures taken
Author: Peter Cowling, North Lincolnshire & Goole Hospitals
Day 2Blood cultures – GPC all bottlesApyrexial, origorsHR 76, BP 120/60Microbiologist advised continue co-amoxiclav
Author: Peter Cowling, North Lincolnshire & Goole Hospitals
Day 3Blood cultures – Group B strepHb 7.5, WCC 8.5, CRP 378Cardiologist referral ?IEMicrobiologist advised MRI leg for ?OM and start genta
as per IE Tx protocolAlso advised ulcer swab
Author: Peter Cowling, North Lincolnshire & Goole Hospitals
Day 4Microbiologist advice – change co-amoxiclav to benzyl
penMRI reported possible OM cuboid + 5th metatarsusT = 37.5o, WCC 8.7, CRP 341ECHO no evidence of IE
Author: Peter Cowling, North Lincolnshire & Goole Hospitals
Day 6Ulcer swab – heavy growth Staph aureusAfebrile, WCC 8.1, CRP 290Orthopaedic referral re OMMicrobiologist advised 6 weeks benpen/amox + clinda
300mg tds and D/W Cons Orthopaedics who felt amputation not indicated.
Author: Peter Cowling, North Lincolnshire & Goole Hospitals
Days 8 -16Day 8 T = 37.5o, rigors, WCC 10.7, CRP 264 Feeling unwell
and miserableDay 11 Apyrexial, WCC 14.8, CRP 323Day 14 Apyrexial, WCC 13.5, CRP 265 Feeling wellDay 16 Itchy rash over leg. Microbiologist advised
continue antibiotics and repeat MRI. If bone destruction, Orthopaedic review.
Author: Peter Cowling, North Lincolnshire & Goole Hospitals
Days 19 - 25Day 19 rash all over body. Microbiologist advised stop
benpen. Continue clinda.Day 20 T = 37.8o, HR 120, BP 140/70, WCC 12.4, CRP 256Day 25 MRI - ‘exuberant osteomyelitic changes with
rapid progressive destruction …..fistula to palmar aspect of foot’
Author: Peter Cowling, North Lincolnshire & Goole Hospitals
Days 26 - 33Day 26 Rash worsening. Microbiologist advised stop
clinda and give co-amoxiclav pending surgeryDay 28 Orthopaedic opinion. Gross destruction of mid
foot extending to Os calci. No option but a BKA. Requested ESR.
Day 33 BKA under cefuroxime prophylaxis
Author: Peter Cowling, North Lincolnshire & Goole Hospitals
Day 35
Profuse diarrhoea………..but that’s for another time!!!!!
Author: Peter Cowling, North Lincolnshire & Goole Hospitals
Day 42Co-amoxiclav stoppedPatient felt much better and less depressedParameters tending to normalDischarged home
Author: Peter Cowling, North Lincolnshire & Goole Hospitals
Learning PointsInsidious infectionDon’t get sidetrackedThorough investigations requiredBroad antibiotic cover requiredSurgery may be inevitableMulti-disciplinary approach???anything else
Author: Peter Cowling, North Lincolnshire & Goole Hospitals